Background: Pancytopenia is defined as the simultaneous presence of anemia, leukopenia, and thrombocytopenia. The present study was undertaken to explore various causes and clinical manifestations of pancytopenia and to correlate them with severity of pancytopenia in adult patients of Malwa region of central India. Materials and Methods: The study was conducted in Department of Pathology of our Institute with the help of clinical departments such as medicine, surgery, oncology, and others. Two hundred and fifty-one admitted adult male and female patients from October 2015 to March 2017 (18 months) presenting with pancytopenia were included in the study. Tests for complete blood count, peripheral smear, reticulocyte count, bleeding time, clotting time, bone marrow aspiration, and trephine biopsy were done. Results: Among all the hematological disorders (202/251) causing pancytopenia, the most common was megaloblastic anemia (98/202, 48.51%) followed by dimorphic anemia (36/202, 17.8%) and aplastic anemia (18/202, 8.9%). Least common causes included hemolytic anemia (2/202) and disseminated intravascular coagulation (2/202), that is, 0.99% each. Conclusion: Thus, a comprehensive, clinical, and hematological study of patients with pancytopenia will usually help in identifying the underlying cause. The early detection of the underlying conditions would also help to enhance the prognosis of patients with pancytopenia.

Pancytopenia is an important clinicohematological entity encountered in day-to-day practice. The incidence of different disorders causing pancytopenia is variable according to geographical distribution and genetic variation.[1],[2],[3],[4] Physical findings and peripheral blood picture provide valuable information in the workup of pancytopenic patients and help in planning investigations on bone marrow samples.[5] Bone marrow evaluation is an invaluable diagnostic procedure which may confirm the cause of suspected cytopenia.[6] If not diagnosed at an early stage, it can be fatal. The underlying pathology determines the management and outcome of the patients. Thus, the present study was carried out to investigate for and to identify the causes of pancytopenia, to find out the frequency of different causes, to determine the incidence of pancytopenia in relation to gender and age, and to compare findings with those of other similar studies from this part of the world.

Materials and Methods

The present study was conducted after approval from the institutional ethics committee. It was an observational study that included 251 adult patients presenting with pancytopenia in institute from October 2015 to March 2017. A thorough clinical history and general examination findings were noted in all cases. Two milliliters of blood sample was collected in K3 EDTA vials of all the study cases. Complete blood cell counts (CBC) were performed on 5-part differential hematology analyzer (Beckman Coulter–LH-750). The hematology analyzer precision was checked on daily basis by running three levels of commercial quality control samples (Beckman) and checking the performance by plotting Levey–Jenning chart and applying Westgard rules with 2 standard deviation limits. Corrective actions were taken in cases of outliers before running patient samples. All the pancytopenia cases were cross-checked by studying peripheral smears and doing manual Neubauer chamber counts with standard procedure simultaneously on same sample. Regular participation was done in external quality assurance program of hematology run by All India Institute of Medical Sciences, New Delhi, to check for accuracy. Six monthly calibration of the analyzer was done as recommended by the manufacturer. Cases were classified as that of pancytopenia based on following criteria:[4]

Hemoglobin <13.5 g/dl in males and 11.5 g/dl in females

White blood cell count <4 × 109/L in both males and females

Platelet count <150 × 109/L.

All CBC proven cases of pancytopenia were further investigated for peripheral smear, reticulocyte count, bleeding time, clotting time, bone marrow aspiration, and trephine biopsy. Peripheral smears and bone marrow aspirates were stained by May–Grunwald–Giemsa and trephine biopsy by hematoxylin and eosin stain. Special stains such as myeloperoxidase, Sudan black B, periodic acid–Schiff's, Perl's stain, and reticulin stain were applied wherever required. Urine examination for hematuria and stool examination for occult blood were done in cases of suspected bleeding. Relevant serological tests were performed in cases of infectious etiology.

All the hematological and demographic parameters were recorded and the observations and results were tabulated as per gender, age group, symptoms, physical signs, bleeding manifestations, bone marrow findings, etiology, and vital hematological parameters. Percent proportion was calculated for above-said groups and following results were derived and analyzed.

Results

A total of 251 cases were included in the present study, of which 144 (57.37%) were male and 107 (42.63%) cases were female with male preponderance.

As per [Table 1], the most common age group of pancytopenia cases was 16–25 years (30.27%) followed by 26–35 years (21.5%) and 36–45 years (18.3%) age group.

The most common symptom was generalized weakness seen in 64.9% of cases followed by fever and dyspnea in 56.1% cases and 19.5% cases, respectively. The most common sign of pallor was present in 142 cases (56.6%). Other physical signs included hepatomegaly in 119 cases (47.4%), splenomegaly in 85 cases (33.8%), bleeding manifestations in 51 cases (20.7%), and lymphadenopathy in 14 cases (5.6%).

Among all the cases of pancytopenia, 20.7% of cases presented with bleeding manifestations, most common was in the form of hematuria (26.92%) followed by hematemesis (19.23%) and gum/gingival bleeding (17.30%). Ten cases of chronic liver disease/cirrhosis, out of 52 cases showed secondary type of bleeding from esophageal varices in the form of hematemesis. Menorrhagia, hemarthrosis, and intracranial bleeding were the least common manifestations (1.92% each).

As per [Table 2], the most common etiology of pancytopenia was megaloblastic anemia (39%) followed by dimorphic anemia (14%) and aplastic anemia (7%). Premalignant and malignant hematological diseases together constituted second common cause of pancytopenia with 10.7% of cases. Acute leukemia (5.6%) formed majority of the malignant hematological malignancy. Infectious and noninfectious liver diseases together formed the third common cause of pancytopenia with total 9.6% of cases.

Table 2: Distribution of pancytopenia cases as per gender and etiology

Among all the hematological disorders (202/251) causing pancytopenia, the most common was megaloblastic anemia (98/202, 48.51%) [Table 3] followed by dimorphic anemia (36/202, 17.8%) and aplastic anemia (18/202, 8.9%). Least common causes included hemolytic anemia (2/202) and disseminated intravascular coagulation (2/202), that is, 0.99% each. In all the disorders, there was a male preponderance except iron deficiency anemia where female preponderance was seen.

Table 3: Distribution of hematological disorders with pancytopenia as per gender and etiology

In the present study, macrocytic normochromic anemia (41.5%) was seen in majority of cases followed by normocytic normochromic anemia (26.7%) and microcytic hypochromic anemia (18.3%). Dimorphic hypochromic anemia was reported in 13.5% cases. Most of the cases of macrocytic normochromic anemia were confirmed as megaloblastic anemia on bone marrow examination.

Bone marrow cellularity was assessed on bone marrow aspirate and was confirmed by bone marrow biopsy for respective age in every case. Hypercellular marrow was observed in 142 cases (56.5%). Megaloblastic anemia was common cause of hypercellularity followed by iron deficiency anemia. Hypocellular marrow was observed in 26 (10.3%) cases of which majority were cases of aplastic anemia (n = 18), that was further confirmed with the help of bone marrow biopsy. One-third of cases (33%) showed normocellular bone marrow and represented majority of nonhematological causes of pancytopenia. Some of the typical histopathological features are illustrated in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9].

The present study was conducted to analyze the various causes of pancytopenia, its age and sex wise distribution and clinical manifestations. The most common cause of pancytopenia reported from various studies worldwide has been aplastic anemia. This is in sharp contrast with the results of the present study where the most common cause of pancytopenia was megaloblastic anemia. This seems to reflect the higher prevalence of nutritional anemia in Indian subjects as well as in developing countries.

In the present study, megaloblastic anemia was the most common cause of pancytopenia, the incidence being 39%. Incidence of megaloblastic anemia as leading cause among pancytopenia cases had been reported to range from 26.42% to 78% by various Indian studies. Incidence of 72% reported by Khunger et al.,[4] 68% by Tilak and Jain,[2] 74% by Gayathri and Rao,[7] 49% by Rangaswamy et al.,[8] 62% by Khanduri and Sharma,[9] 72.6% by Javalgi and Dombale,[10] 26.42% by Subrahmanyam and Padma,[11] 38.1% by Reddy et al.,[12] 42.9% by Jella,[13] and 78% by Tekwani et al.[14]. A possible explanation of such large number of patients presenting with nutritional anemia in our study can be extremes of age, nutritional deficiencies, malabsorption, parasitic infestations, chronic gastrointestinal, genitourinary bleed, etc. In our study, the age of the patients with megaloblastic anemia ranged from 15 to 74 years and male: female ratio was 1.39:1. This finding is in accordance with the studies by Jha et al.[15] On peripheral smear examination, 98 of 251 cases were found to be pure megaloblastic anemia where macroovalocytosis with anisopoikilocytosis (seen in all cases) and hypersegmented neutrophils (86/98, 87.7%) were found to be the main features. Rangaswamy et al.[8] also found macroovalocytosis with anisopoikilocytosis in all cases. Khodke et al.[16] found anisocytosis in 20/22 cases and Tilak and Jain[2] in 51/53 cases. Khodke et al.[16] found hypersegmented neutrophils in 20/22 cases (91%).

Dimorphic anemia (14%) was the second most common cause of pancytopenia in the present study with 35/251 cases. Raphael et al.[17] found 8.7% cases of dimorphic anemia as the second most common cause and Prabhala et al.[18] found 14.53% cases of dimorphic anemia as the third most common cause of pancytopenia in their study. Khodke et al.[16] reported dimorphic blood picture in 10/22 (45.5%) and Gayathri and Rao[7] reported in 39/72 cases (54.2%).

A dimorphic blood film can be seen in several circumstances, it can occur when iron deficiency anemia responds to iron therapy, after the transfusion of normal blood to a patient with a hypochromic anemia, sideroblastic anemia, macrocytic anemia posttransfusion, unmasking of iron deficiency following treatment of megaloblastic anemia, delayed transfusion reactions, and dual deficiency of iron and either Vitamin B12 or folic acid.

Aplastic anemia was the third most common cause and constituted 7.1% (18/251) cases of pancytopenia which is comparable to the studies of Tilak and Jain[2] 7.7%; Khunger et al.,[4] 14%; Rahim et al.,[19] 14.15%; Rangaswamy et al.,[8] 14%; and Khodke et al.,[16] 14%.

The Indian and Asian studies that reported aplastic anemia as leading cause may be result of low sample size, selective bone marrow aspiration, and biopsy studies avoiding bone marrow examination in nutritional anemia proven by biochemical methods and variation in incidence of Vitamin B12 and folic acid deficiency in their study regions based on dietary habits.

We encountered 5.9% (15/251) cases of iron deficiency anemia associated with pancytopenia. In a study by Javalgi and Dombale,[10] 12.2% (13/106) cases of iron deficiency anemia were found. Although iron deficiency is associated with a reactive thrombocytosis, increasing severity of iron deficiency leads to normalization and occasionally even decrease platelet counts. The exact mechanism of this is unclear but may be related to the alteration in the activity of iron-dependent enzymes in thrombopoiesis and leukopoiesis. In our study, 2/251 (0.7%) cases of sickle cell anemia presented with pancytopenia. Rahim et al.[19] in their study found 3/424 (0.7%) cases of hemolytic anemia presenting with pancytopenia.

A single case (female) of hypersplenism was encountered in the present study. In a study by Javalgi and Dombale,[10] 1/106 (0.9%) case of hypersplenism was reported similar to our study.

Leukemia was fifth common cause of pancytopenia and constituted 5.6% (14 cases) of our study, which is comparable to the studies by Khunger et al.[4] and Rangaswamy et al.[8] who reported incidence of 5%, Tariq et al.[20] (14%). Qamar and Aijaz[21] reported higher incidence of leukemia (11%) in their study. Santra and Das[22] and Ishtiaq et al.[23] reported lower incidence of leukemia (both 1.8%) as compared to the present study.

In the present study, 13 cases (93%) out of total leukemia cases were acute myeloid leukemia (AML) and 1 case (7%) of ALL was observed. In the study by Tariq et al.,[20] ALL constituted 12% cases and AML 2% cases out of 14% of total cases, whereas Dash et al.[24] reported AML to be 12.8% of total pancytopenia cases.

The incidence of myelodysplastic syndrome (MDS) in our study was low (2.7%). MDS is being reported to range from 0.94% to 8.3% by various studies.[4],[15],[21],[25],[26] Thus, the average incidence of MDS in various studies is close to that we reported in the present study.

Six cases (2.4%) of lymphoma presented with pancytopenia, of which 5 were male and 1 female. Two cases were diagnosed as Hodgkin's lymphoma and 4 were categorized as NonHodgkin's lymphoma. In stage IV widespread phase, lymphoma cells infiltrate the bone marrow causing pancytopenia. In studies by Subrahmanyam and Padma,[11] 4/106 (3.77%) and Rahim et al.,[19] 5/424 (1.17%) cases were diagnosed as non-Hodgkin's lymphoma.

Four cases (1.6%) of nonleukemic malignancies were seen in which 2 cases were of metastatic adenocarcinoma lung infiltrating bone marrow causing pancytopenia. One case was of 50-year-old female with glioblastoma multiforme and one case of metastatic carcinoma with unknown primary in 18-year-old female.

In studies by Mansuri and Thekdi,[27] 1/50 (2%) case and Vaidya et al.,[28] 1/83 (1.2%) case of metastatic adenocarcinoma were seen. In a study by Dasgupta et al.,[29] 4/258 (1.6%) cases and in the study by Hirachand et al.,[30] 1/52 (1.92%) cases of metastatic carcinoma causing pancytopenia were found. These findings of various studies are in concordance with our study.

Among the nonhematological causes of pancytopenia, we encountered 18/251 (7.1%) cases of chronic liver disease out of which 5 cases were of alcoholic liver disease/cirrhosis of liver and 13 cases were of nonalcoholic etiology that ultimately ended up into cirrhosis-like features. In a study by Yokuş and Gedik,[31] 9/137 cases (21.15%) were diagnosed as chronic liver disease. In a study by Vaidya et al.,[28] 3/102 (2.9%) cases of chronic liver disease (CLD) with pancytopenia were seen. In a study by Thakkar et al.,[32] 4/100 (4%) cases of CLD were diagnosed, all were of alcoholic liver disease.

Among the infectious etiology, we encountered 7/251 (2.8%) cases of dengue fever causing pancytopenia. In a study by Vaidya et al.,[28] 1/102 (1%) case of dengue was reported. In a study by Jella,[15] 1/56 (1.8%) case of dengue was found. In a study by Santra and Das,[22] 1/111 (0.7%) dengue case with pancytopenia was seen.

Dengue fever is frequently associated with cytopenias, particularly thrombocytopenia. This may be due to either bone marrow suppression or due to immunological effect. Bone marrow aplasia however may rarely be seen in patients with dengue fever and needs to be diagnosed early, as these patients have favorable outcome with immunosuppressive therapy.

In our study, we reported 6/251 (2.4%) cases of pancytopenia with viral hepatitis. Out of 6 cases, 3 cases were hepatitis B surface antigen reactive so they were diagnosed as hepatitis B and 3 cases had positive anti-Hepatitis C virus (HCV) antibodies. HCV as a cause of pancytopenia could not be ruled out. Suppression of bone marrow by HCV could be a possibility. In studies by Santra and Das[22] and Ishtiaq et al.,[23] 2/111 (1.8%) and 2/100 (2%) cases of hepatitis B were seen.

In the present study, malarial infestation was seen in 5 cases (1.9%). Two cases were reported as Falciparum malaria and three as Vivax malaria. In the study of Hossain et al.,[33] chronic malaria was the second most common cause of pancytopenia. Khunger et al.[4] reported the incidence of malarial cases as 1%, Gayathri and Rao[7] as 1.93%, Tilak and Jain[2] as 3.9%, Kumar and Raghupathi[26] as 3%, and Santra and Das[22] as 1.8%. Thus, the finding of our study is in concordance with the above studies.

Enteric fever was encountered in 3/251 (1.2%) cases (2 males, 1 female) which is mainly caused by Salmonella More Details typhi and paratyphi. In a study by Santra and Das,[22] 2/111 cases (1.8%) of enteric fever with pancytopenia were seen, while in a study by Hossain et al.,[33] 1/50 (2%) case of enteric fever was reported similar to our study.

Only one case (0.3%) presented with history of human immunodeficiency virus (HIV) and was taking antiretroviral therapy. In studies by Santra and Das,[22] 2/111 (1.8%), Khodke et al.,[16] 1/166 (0.6%), Ishtiaq et al.,[23] 1/100 (1%), and Rangaswamy et al.,[8] 1/100 (1%) of HIV cases presenting with pancytopenia were reported similar to our study.

Systemic lupus erythematosus (SLE) (autoimmune disease) was seen in 2/251 (0.7%) cases with pancytopenia in the present study. Both the patients were female of middle age group. In a study by Javalgi and Dombale,[10] 3/106 (2.8%) cases and by Santra and Das,[22] 5/111 (4.5%) cases of SLE were reported with pancytopenia. One case each of sarcoidosis and tuberculosis was found in the present study. Similar cases are being reported by Yokuş and Gedik[31] and Reddy et al.,[12] respectively.

Conclusion

Pancytopenia is feature of many transient illnesses or serious life-threatening diseases. Since a large number of causes for pancytopenia are remediable and reversible, accurate diagnosis and timely intervention may be lifesaving and will definitely have an influence on the morbidity and mortality in these patients. Thus, a comprehensive, clinical, and hematological study of patients with pancytopenia should be carried out which can help in proper identification of underlying cause.